Cervical spondylosis

In one minute

Cervical spondylosis is the wear of the neck's discs and small joints that comes with age. Almost everyone gets some of it: in a study of 1,211 volunteers with no neck symptoms, 87.6% had disc bulging on MRI (magnetic resonance imaging). In this region it is usually called cervical osteochondrosis, and many patients arrive with that label on an old report. It feels like a stiff, aching neck that is worse after long hours at a screen or the wheel, sometimes with pain into the shoulder blade. It is diagnosed from the history and the examination; the scan confirms wear but cannot say whether the wear is the cause of the pain. Treatment is exercise, sensible pain relief and time. Surgery is for the minority in whom spondylosis pinches a nerve root or the spinal cord.

What it is

Between each pair of neck vertebrae sits a disc, and behind it a pair of small facet joints; at the sides of the disc are the tiny uncovertebral joints. With time the disc dries and loses height, the joints take more load and grow bony spurs (osteophytes), the ligaments thicken, and the openings for the nerves and the cord narrow a little. That whole process is spondylosis. The narrowing it produces is described on the cervical spinal stenosis page; a pinched root and a squeezed cord have their own pages.

A word about the word. Osteochondrosis is what Soviet and post-Soviet medicine called these same changes on an X-ray or MRI, and for decades almost every neck pain was filed under it. The label is not wrong; it describes real wear. What it cannot do is explain a symptom on its own, because the same wear is present in most people who feel nothing. If your report says osteochondrosis, degenerative-dystrophic changes or spondylosis, it is telling you your age, and the question that matters is whether anything is being compressed.

Causes and risk factors

Age is the dominant factor and the numbers are striking. In the volunteer study of 1,211 people aged 20 to 70, disc bulging increased with age in frequency, severity and number of levels, and was already present in 73.3% of men and 78.0% of women in their 20s. In an earlier study of 63 symptom-free volunteers, a disc was degenerated or narrowed at one or more levels in 25% of those under 40 and in almost 60% of those over 40. Neck pain itself is one of the top five chronic pain conditions in prevalence and years lost to disability, and the BMJ review of 2017 names genetics and psychosocial factors as risk factors for pain persisting. The role of heavy work, screen hours or particular jobs in causing spondylosis has not been measured well enough to give you a figure, and we will not invent one.

How it develops

The disc loses water, then height; the ring cracks and bulges; the load shifts to the facet and uncovertebral joints, which respond with spurs; the ligament behind the cord thickens. Most of this happens without pain. When there is pain, it can come from the disc, the joints or the muscles that guard them, and it can be mixed in character: the BMJ review reports that nearly half of people with chronic neck pain have neuropathic or mixed features. Spurs and bulges become a different problem when they narrow a nerve exit (foraminal stenosis) or the canal (central stenosis); the volunteer studies found cord compression in 5.3% of adults aged 20 to 70 and foraminal stenosis in 20% of those over 40, all of them without neck symptoms by design.

Symptoms

Typical spondylosis feels like an aching, stiff neck, worse with sustained posture and better with movement, sometimes with pain spreading to the top of the shoulder or the shoulder blade, and sometimes a grinding sensation on turning. It differs from radiculopathy, which sends pain down one arm in a strip, and from myelopathy, which makes both hands clumsy and the walk unsteady.

Two symptoms deserve honest paragraphs, because patients are often told the neck explains them. Headache first. The International Headache Society recognises cervicogenic headache, but its criteria require at least two pieces of evidence of causation: a headache that began with the neck disorder, improves as the neck improves, is provoked by neck movement with reduced range, or stops after a diagnostic block of a neck structure. Its notes state that imaging findings in the upper neck are common in people without headache and are suggestive but not firm evidence, and that spondylosis may or may not be a valid cause depending on the individual case. Features that point toward the neck are pain locked to one side, pain provoked by pressing on neck muscles or moving the head, and pain that spreads from back to front.

Dizziness second. A narrative review of cervical vertigo concludes that whether it is an independent entity remains controversial, that the diagnosis depends mostly on the patient's subjective feelings and lacks positive signs or specific tests, and that neurological, vestibular and psychosomatic disorders must be excluded first. In a matched cohort of 3,638 patients with cervical spondylosis, 10.2% were diagnosed with dizziness within a year, against 8.6% in matched patients with lumbar spondylosis. The authors concluded that dizziness attributable to cervical spondylosis is uncommon and warned against diagnosing a cervical cause on the strength of a history of spondylosis. We agree with them.

Diagnosis

The history and examination decide: where the pain is, what provokes it, whether it runs into an arm, whether the hands are clumsy, whether the reflexes are brisk. Imaging follows the American College of Radiology criteria. For neck pain without red flags, plain radiographs are appropriate first imaging, with the caveat that spondylotic changes are commonly found and can give both false-positive and false-negative impressions. Non-contrast MRI is usually appropriate when there is new or increasing radiculopathy, MRI with contrast when infection or cancer is suspected. For a suspected cervicogenic headache without a neurological deficit, imaging is not always indicated.

The words in the report are less alarming than they sound. Disc desiccation means the disc is dry; height loss means it is thinner; a bulge is the whole disc spreading past its edge; a protrusion is a focal bump; an osteophyte is a bone spur; uncovertebral or facet hypertrophy means the small joints are enlarged; foraminal narrowing means the nerve exit is tighter; Modic changes are signal changes in the bone next to a worn disc; canal stenosis means the tunnel is narrower; cord signal change means the cord itself shows a mark. In the volunteer study of 63 people, scans were read as abnormal in 19%, and in 28% of those over 40. Every one of these findings is only meaningful next to a symptom that matches it. If you send a scan, photograph the side-view T2 series, the cross-sections at any level the report singles out, and the report, and tell us in a sentence what actually hurts and where it goes.

Treatment without surgery

Exercise has the strongest evidence, and it is specific. The Cochrane review of 27 trials with 2,485 participants found moderate-quality evidence that strengthening of the neck, shoulder-blade and upper-limb muscles reduces chronic neck pain by a moderate to large amount immediately after treatment and in the short term, that combined strengthening and stretching helps pain up to long-term follow-up and improves function, and that stretching alone or endurance work alone has minimal effect. There was no high-quality evidence, so uncertainty remains, but the exercises were safe. The BMJ review reaches the same place: among non-drug treatments the evidence is strongest for exercise, with weaker evidence for massage, acupuncture, yoga and spinal manipulation.

Medication is for short episodes. The BMJ review reports that non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants are effective for acute neck pain; which drug, at what dose and for how long is the doctor's decision. For the small group whose pain comes from a facet joint, radiofrequency denervation has weak supporting evidence, and epidural steroid injections have weak evidence, and only for radiculopathy. Honesty about the course: most acute episodes resolve on their own, but more than a third of people still have low-grade symptoms or recurrences a year later, and the radiology criteria note that nearly 50% have ongoing or recurrent symptoms. Spondylosis is managed, not cured, and the management is mostly in your own hands.

When surgery is considered

Not for the wear itself, and not for neck pain alone. The BMJ review's summary is that surgery is more effective than conservative treatment in the short term but not in the long term for most patients, and that a period of clinical observation is a reasonable strategy before any operation. Surgery enters the conversation when spondylosis produces one of two things: a pinched root with arm pain or weakness that has not settled after a proper course of conservative care, or compression of the spinal cord with signs of myelopathy. The indications and the timing for each are on the cervical radiculopathy and cervical myelopathy pages; myelopathy in particular should not be left to wait.

Surgical options

When spondylosis needs an operation, the operation is for what it is pressing on. A bone spur or bulge narrowing one nerve exit is treated with a posterior endoscopic cervical foraminotomy through a 7 mm incision that keeps the disc. Thickened ligament and arch compressing the cord from behind at one or two levels can be treated with an endoscopic cervical decompression. A disc-spur complex pressing on the cord from the front, or several worn levels with a neck that has lost its curve, is treated with ACDF (anterior cervical discectomy and fusion), which removes the disc and fuses the level. Cervical disc replacement is an alternative to fusion for a single mobile level with root symptoms, and laminoplasty is the open posterior option for long multilevel compression. No operation removes spondylosis from a neck; each removes a specific pressure.

How we treat it at spine.uz

We are Tashkent's first endoscopic spine team: five surgeons operating as one team, trained in South Korea, Japan, Germany and the USA, with 27,600+ endoscopic and spine operations between us. The first step costs nothing. Send your MRI and the report on Telegram or WhatsApp and a doctor from the team replies by voice within 48 hours. Wear on a scan is not by itself a reason to operate, as the volunteer studies above show, and a report that says osteochondrosis is no exception. The in-person consultation and any operation are paid.

When an operation is the answer, the team performs the posterior endoscopic foraminotomy and the posterior endoscopic decompression, both through a 7 mm incision without screws or implants, as well as ACDF, cervical disc replacement and multilevel cervical operations; which one fits follows the logic set out under surgical options. Most of our endoscopic decompressions are done under local anaesthesia with sedation, the anaesthetist and surgeon deciding per patient, and most patients walk on the day of surgery and go home within 24 hours. Across the team's operations our complication rate is well below 1%. Every patient leaves with a written team conclusion.

Recovery and outcomes

For spondylosis without nerve or cord involvement, the outcome depends on habit rather than on a procedure. Most acute episodes settle; more than a third of people have low-grade symptoms or recurrences beyond a year; and a strengthening programme for the neck and shoulder-blade region is the one measure with moderate-quality evidence for reducing chronic pain. Where a root or the cord is decompressed, recovery follows the pattern on the cervical radiculopathy and cervical myelopathy pages: root pain eases quickly after a foraminotomy, cord function improves over months and rarely returns fully.

Living with it and prevention

Move often and sit less; a screen at eye level and a break every hour cost nothing. Do the strengthening; stretching alone does little. Treat a flare early and briefly. Do not accept osteochondrosis as an explanation for dizziness or headache until the ears, the blood pressure and the nervous system have been checked. And do not let anyone operate on a label.